The best defense is a good documentation offense online nursing. The longterm care pocket guide to nursing documentation is the only documentation specific tool that your nurses can use to quickly break down coding and documentation complexity. This online nursing continuing education course discusses what errors to avoid in patient documentation, concepts of medical record and professional negligence, in order to prevent injury for the patient or legal trouble for the nurse. Jul 26, 2018 martin chitwood 5 common legal mistakes that nurses make are you prepared for a medical malpractice suit. The quality of nursing documentation is an important issue for both patients and nurses. Browse the amazon editors picks for the best books of 2019, featuring our. As a result, legislation and regulations emerged relating to long term care facilities and new litigation lawsuit possibilities occurred. This excerpt is adapted from hcpro s new book managing documentation risk. It takes years of training, constant retraining, and a lot more than just book smarts to be a good doctor. Jun 25, 2016 a recently filed lawsuit alleging that a faulty electronic health record system caused patient harm may be among the first in a wave of such cases, even though most experts say the latest ehr. Court case points out importance of nursing documentation. Jul 16, 2009 documentation why do patients sue for malpractice. Obviously quality nursing documentation enhances patient care as this leads to better communication of the issues.
Not only fired you can also lose your nursing license and be on the losing end of a lawsuit. Often, in a lawsuit, plaintiffs attorneys will tell the jury the old adage, if its not in the record, it didnt happen. No matter how skilled or experienced you are, inaccurate or incomplete nursing documentation can mean serious trouble for your patientsand for you if youre ever involved in a lawsuit. The purpose of this course is to present key topics related to nursing documentation.
A wrongful death lawsuit has been filed against nurses. Wrongful death lawsuit filed over negligence of nurses at. I only came into assist when i saw her falling, and eased her down to the floor. Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete security nurses safeguard client health information by maintaining confidentiality of the record nurses ensure information retention consistent with the standards and legislation policy. May 08, 2018 i found out that a patient has filed a lawsuit against my health region for a fall in hospital from 2 years ago. Nurses documentation wins case for hospital clinical. Part twonursing practicediscusses nursing practice and documentation including. Students and professional nurses at any level of clinical practice will find this book to be a vital resource on the basic legal concepts and principles of malpractice, liability, and risk management, and their implications for the profession. Nursing responsibilities include patient advocacy, even when the role is adversarial to the physician.
Principles and perils of documentation karen fogelman, rn, crno, clnc. Identify characteristics of nursing documentation that support a legal defense of. Nursing documentation 101 101zzzzzzzzzzzzzzzzzzzzzzz. If the nurse is employed by an independent doctor, he or she may be for example, a nurse who gives a patient too much of a medication than what the doctor ordered has clearly committed medical. Explain why documentation is important to health care providers. For nurses, who are on the front lines of defense in the medical field, being adequately trained early on proper documentation can help avoid such medical errors, save lives and help protect their employers. Documentation may not be nurses favorite activity, but nurses who find themselves involved in litigation who have documented thoroughly will thank themselves later. Anas principles for nursing documentation overview of nursing documentation 3 overview of nursing documentation n clear, accurate, and accessible documentation is an essential element of safe, quality, evidencebased nursing practice. Learning objectives after successful completion of this course, you will be able to. Some of the most common medical documentation errors can also be the most disastrous. No matter how skilled or experienced you are, inaccurate or incomplete nursing documentation can mean serious trouble for your patients. Documentation describing the negligent behavior often used terms such as.
Documentationdocumentation nurses have a duty to maintain complete and accurate recording of all the care thy provide. A guide for nurse managers, second edition, by patricia a. Apr 16, 2018 nursing documentation can be a strong evidence to a lawsuit that will help in solving the case. Identify the basic information that is required when documenting in the medical record. Jun 21, 2018 can i get fired for not having enough nursing documentation. Despite a growing sense of alarm among policymakers, little is known about these lawsuits scale, dynamics, or.
She pretty much threw the book at them, landin said. Nurses practice across settings at position levels from the bedside to the administrative office. Can i get fired for not having enough nursing documentation. An rns careful notetaking protects hospital from liability. Nurses, negligence, and malpractice article nursingcenter. Malpractice suits against nurses on the rise nurse lawyer. Narrative charting nursing student assistance allnurses. Filing a lawsuit against a nurse medical malpractice help nurses can also be at fault for the hospital is often the defendant in lawsuits. A welldocumented patient medical record is one of the best ways to stay out of the courtroom. Replete with reallife examples and information from hundreds of court cases, the book covers the full range of contemporary concerns, including computer documentation, cloning, stem cell research, pain management, euthanasia, prescribing, privacy.
A second area of liability is that of lack of followthrough with a physician or other appropriate healthcare provider. Although she didnt end up as a defendant in a lawsuit, her remark caused her more grief than the physician caused the patient. Legally, it appears the most common area of liability for case managers, including nurse managers, is basing a decision concerning a patient s care on cost savings alone, without regard to the quality of the treatment regimen. Lax documentation can reflect lapses in care or inappropriate care, providing the basis for a lawsuit. Can someone please tell me what is the best comprehensive book on documentation. A civil lawsuit alleging negligence is the predominant concern nurses have when they turn their minds to this issue. Typically the expert is another nurse with a similar skill set or similar expertise in the standard of care as that of the defendant nurse. A nurse once documented that a physician had a poor bedside manner. Plus, improper documentation can open up an employer to liability and malpractice lawsuits. Nursing documentation is a critical component in high quality patient care and safe, effective nursing practice that is legally and ethically sound. Registered nurses working in todays fast paced, hightech health care environments are aware of their professional accountability and that, at some point, they may be involved in legal proceedings related to their practice. Legal considerations for documentation, as appropriate.
Tightening up your documentation can go a long way. Portions of this article appear in her book documentation skills for quality patient care. Documentation that is complete and timely is the nurses best defense against litigation. Describe those particular issues that require documentation in the medical record. She was full did not document that the physician or code status as far as goals of care. This course presents tips on improving documentation. An inherent part of health care, medical malpractice lawsuits loom perpetually over healthcare practitioners. What is the role of the medical record in how legal cases are screened for merit. Martin chitwood 5 common legal mistakes that nurses make. Nurses are required to do more than simply follow physicians orders. Longterm care pocket guide to nursing documentation. Documentation is usually included in the progress notes.
Documentation should be a complete record of nursing. If a specific action was not written in the documentation, this particular intervention is not valid even it was given by the nurse. The nof defines communication as the ability to interact effectively with patients, families, and colleagues, fostering mutual respect and shared decisionmaking, to enhance patient satisfaction and health outcomes. In this case it is alleged a licensed vocational nurse lvn assaulted an elderly male nursing home resident.
The patient expects the care and the nurse is the provider of care. The dos and donts december 20, 2012 nursing articles 48,768 views if you are a registered nurse who dreads documenting the care you provide to patientsyou are not alone. The nursing notes made it clear that the patients chief complaint was hip pain and fever. The dos and donts december 20, 2012 nursing articles 48,768 views if you are a registered nurse who dreads documenting the care you provide to. Its easy to get complacent about documentation when youve gone a few years without the threat of a lawsuit. Jim tells alex that it would be a great help if he could give 4.
This month we look at a case in which a nurse s careful documentation of a patients neurologic examination findings saved the. Specialty sections provide important and specific guidelines for hospice care and maternalchild care. The perinatal nurses guide to avoiding a lawsuit is replete with case studies and resources highlighting areas of litigation for which perinatal nurses are at greatest risk and addresses strategies to reduce those risks. What everyone who has practiced medicine knows, however, is that many things dont make it to the chart. However, there was no documentation one way or the other about the co n. Defending yourself through documentation american nurse. Mar 11, 2010 wrongful death lawsuit filed over negligence of nurses at hospital march 11, 2010 written by.
Documentation begins the moment the patient arrives at the hospital, clinic or unit and continues until discharge. More and more nurses are being named defendants in malpractice lawsuits. All nursing interventions listed in the notes are considered to be accurate and reliable. Introductory chapters describe documentation, the medical record systems of nursing documentation, and current jcaho and ana standards related to documentation. When it comes to nursing documentation, knowing how to accurately document a patient can literally mean life or death. Inadequate nurses notes lead to lawsuit caring for the ages. Telehealth nursing practice essentials medical books. Part sevenlitigation of nursing malpractice claims focuses on the legal. You may need to keep a small pocket note book with. Although roles have evolved, the patient remains the center of focus. However, lapses in applying these principles create problems when documentation is presented as evidence to defend against allegations of malpractice, negligence, or failure to meet standards of care. Our resident legal expert, martin chitwood talks medical malpractice and how its a form of personal injury law where the actions of a health care provider, the treatment facility, or both, have led to a negative outcome for a patient. It will reduce documentation errors, help documentation stand up to survey scrutiny and help create more lawsuit proof documentation record. The assault was so severe that the resident required hospitalization and the lvn would later be charged with a felony.
Feb 22, 2018 plus, improper documentation can open up an employer to liability and malpractice lawsuits. Details of the defamation claim a reader asked if she could sue her nurse manager over false oral statements about her nursing care that resulted in a transfer to another unit and a fourweek leave of absence cause by the stress about the statements and the transfer. Why is documentation important in nursing profession. Nursing negligence lawsuits are often lost because the strategies for documentation that will protect and defend you in a lawsuit and promote safe. The expert will look at the nursing documentation for clues and evidence that the care rendered wasnt consistent with appropriate nursing care in order to form an expert opinion. Four lawsuits filed on behalf of former nurses of capital health regional medical center in trenton, n. Alex, another nurse on the unit offers to help jim out. Lawsuits against nurses for medication errors justice. Nursing notes can become unexpected problem for ep during. Again, the nursing staff and diabetic ketoacidosis. After completion of the best defense is a good documentation offense, the participant will be able to. Lawsuits against nursing homes are a relatively recent phenomenon. Fingerpointing can trigger a lawsuit, with your documentation as the main attraction. Our nursing program has offered no formal training in documentation.
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